CHAPTER IV - Intervention Methods for Young Children with Communication Disorders

INTERVENTION METHODS

This chapter provides evidence-based
recommendations about appropriate interventions for communication
disorders in young children. The panel used the available
scientific evidence about the efficacy of specific intervention
methods as the basis for developing these guideline
recommendations. When such evidence was not available, guideline
recommendations were made based on consensus opinion of the
panel.

Evaluating the efficacy of interventions

Over the past decade, there has been
an emphasis on outcomes research in the fields of health care,
social services, and education. The primary focus of outcomes
research is to evaluate how specific interventions affect
functional outcomes for individuals and families. This is sometimes
also known as treatment efficacy research.

A number of recent articles have
systematically evaluated the research evidence on treatment
efficacy of specific speech/language interventions for certain
communications problems in adults (Holland, 1996; Conture, 1996)
and in young children (McLean and Cripe, 1997). According to
Olswang (1990), the goal of such treatment efficacy research for
speech/language problems is to answer the following important
questions:

"Does treatment work for this condition?"

"Does one treatment work better than another for this condition?"

"What specific target behaviors, associated with this condition, are altered by the treatment?"

When evaluating interventions for
communication disorders, it is important that appropriate research
designs be used to determine if the outcomes observed are clearly
due to the intervention evaluated. Most young children, even those
with communication disorders, show some improvement in speech and
language abilities with time alone (this is often referred to as a
maturation effect). Therefore, in evaluating the efficacy of a
speech/language intervention for young children, it is important to
determine if the intervention brings about improvement in a child's
communication over and above what would be expected to occur by
maturation alone.

Studies that have evaluated
treatment efficacy of speech/ language interventions have tended to
use either group study designs or single-subject study designs
(McLean and Cripe, 1997). This guideline reviews treatment efficacy
studies that use either of these types of study design, which are
described briefly below.

Evaluating interventions using group study designs

In general, to demonstrate that a
treatment is effective, the strongest evidence is provided by group
studies comparing a group receiving a speech/language intervention
to an equivalent group receiving no treatment (non-treatment
control group). Group comparison studies that include a
non-treatment group are able to control for potential bias due to
maturation of the subjects.

Studies that evaluate two comparable
groups receiving different treatments are useful for determining
which treatments may work better. Some of these studies also
include non-treatment control groups that may allow conclusions to
be drawn about the overall effectiveness of each treatment. Group
studies of speech/language interventions are most useful when they
specify the characteristics of the children being treated and the
specific intervention targets (such as grammar or vocabulary size)
targeted by the intervention.

Evaluating interventions using single-subject study designs

Single-subject design studies of
speech/language interventions are also useful in providing evidence
about treatment efficacy (Ingham and Riley, 1998; McLean and Cripe,
1997). Single-subject design studies involve reporting data
individually for each subject over time. Some single-subject design
studies may report data for only one subject. However, it is
considered more methodologically sound to present data for multiple
subjects to evaluate if the treatment can be effective for more
than one individual. For this guideline, a single-subject design
study had to present data for at least three subjects to be
considered adequate evidence about efficacy.

Single-subject design studies can be
useful for demonstrating the overall effects of a given treatment
and for investigating differential effects of individual components
of a treatment program. Single-subject design studies also
highlight individual differences in the effects of a treatment and
can focus on the treatment's effect on specific target
behaviors.

Strengths of the research literature on this topic

Recent research literature on
speech/language interventions in young children that was reviewed
for this guideline had many strengths. A reasonable number of
well-designed scientific studies were found that evaluated
speech/language interventions in young children using either group
or single-subject research designs.

A number of these studies evaluated
some children under 3 years old. Several other studies were
reviewed that evaluated children who were slightly older than the
target age group (studies that evaluated children age 4 to 6 years
old) because the results were felt to be somewhat generalizable to
children under the age of 3 years. In many studies, the age range
of the subjects studied was fairly narrow, an important attribute
since communication skills in young children can change rapidly
over time.

Most of the studies used
well-described assessment methods and/or appropriate standardized
tests to measure both the child's baseline levels of communication
skills and the outcomes of the interventions. Many studies provided
detailed operational descriptions of the intervention methods. In
addition, most of the studies used standardized language tests to
evaluate outcomes of the intervention and took steps to control for
bias in outcome assessment.

Many well-designed group studies
compared outcomes for a group receiving a specific intervention
with outcomes of groups receiving either no intervention or a
different intervention. These studies also included appropriate
measures to reduce bias and control for confounding factors in
evaluating the studies' outcomes.

Many well-designed single-subject
studies used various methods, such as multiple baseline designs, to
ascertain if outcomes could be attributed to the intervention
versus some other factors. Many of these studies also used multiple
baseline approaches to determine if effects of an intervention
would generalize to various subjects, behaviors, and
conditions.

Limitations of the research evidence on this topic

There were also several limitations
in many research studies evaluating speech/language interventions
in young children. In a few studies, descriptions of intervention
procedures were not detailed enough to allow others to correctly
administer the therapy. In some studies, the interventions used
were specific to the individual children studied rather than to
standardized treatment procedures. Another problem cited by some
researchers was the difficulty of acquiring and maintaining an
untreated control group equivalent to the intervention
group.

Weighing information on harms and costs

For all evidence-based clinical practice guidelines, the fundamental consideration when developing
guideline recommendations is whether the evidence of potential
benefits outweigh the evidence of potential harms enough to justify
the costs of an intervention.

In evaluating the scientific
evidence on the speech and language interventions for this
guideline, the panel found that there were few, if any, direct
(physical) harms associated with any of the interventions
evaluated. For this guideline, the panel considered that the costs
of an intervention method depend on the intensity, frequency, and
duration of the intervention. Because these factors will vary
greatly depending on the characteristics and progress of the
individual child, the panel chose not to make global statements
about costs for specific intervention methods. Therefore, the
primary determining factor in developing guideline recommendations
was evaluation of evidence about efficacy of the
intervention.

Using scientific evidence as the basis for recommendations

For each speech/language
intervention method evaluated, the panel considered both quality of
the research studies reviewed and applicability of the findings to
the guideline topic (intervention for communication disorders in
children from birth to age 3 years old). When relevant and
high-quality research evidence was found on the efficacy of an
intervention, the panel used this evidence as the basis for
guideline recommendations. When such scientific evidence about
efficacy was not available, the guideline recommendations were
developed through consensus opinion.

General Intervention Approach for Young Children with Communication Disorders

General Strategies for Intervention

Recommendations

Importance of early identification and intervention

It is important to identify
children with communication disorders and begin appropriate
interventions as soon as possible. Early intervention may help
speed the child's overall language development and lead to better
long-term functional outcomes.
[D1]

For a child to make progress in a
particular component of language (such as grammar or
pronunciation), it is important to focus intervention directly on
that component, since improvement in one area may not necessarily
generalize to improvement in other areas. [B]

For most young children with
communication disorders, it is recommended that intervention focus
first on increasing the amount, variety, and success of verbal and
nonverbal communication and then, if necessary, on
intelligibility.
[D1]

While encouraging intelligible
speech, it is important that progress not be slowed by focusing on
speech productions that are not expected at the child's particular
developmental level.
[D1]

When speech intelligibility is
significantly reduced or there are concurrent oral-motor deficits,
it is recommended that intervention address these concerns.
[D2]

For some children, it is
recommended that intervention include attention to comprehension of
words, sentences, and responses to commands as well as receptive
identification of objects and pictures (both with and without
contextual support).
[D1]

When assessing or treating a child
with a communication disorder, it is important to look for and
adequately address any co-existing medical and developmental issues
(such as gross motor delays, possible late-onset or progressive
sensorineural hearing loss, or chronic ear problems such as otitis
media). [D2]

Ongoing monitoring and appropriate modification of the intervention

It is recommended that any
intervention be tied to ongoing assessment and modification of
intervention strategies as needed. [D2]

It is recommended that no form of
therapy be continued without documentation that the intervention is
effective for the child.
[D2]

Modification of intervention
strategies might be appropriate when any of the following
occur:

target objectives have been achieved

progress is not evident

regression is noted

there is an unexpected change in a child's behavior or health status

there is a change in the intervention setting or the child's environment [D2]

Periodic comprehensive evaluation

In addition to ongoing monitoring
and assessment, it is important to perform periodic comprehensive
evaluations to assess the child's individual progress and to
compare progress to age-expected development. [D2]

It is recommended that a
comprehensive evaluation be performed at least on an annual basis.
Depending on the instrument and the purpose, it may be appropriate
to complete some types of assessments as often as every six
months. [D2]

The Professional's Involvement in the Intervention Process

Recommendations

It is important that there be
ongoing communication and coordination of efforts among team
members to accomplish agreed-upon intervention goals. [D2]

It is important that all
professionals collaborate in coordinating and integrating
techniques and approaches when working with the child and
family. [D2]

It is recommended that the
professional make some provision for regular communication and
consultation with relatives, babysitters, and other child-care
providers (such as daycare, toddler group, nursery school, or
preschool) who function as caregivers of the child for significant
amounts of time during the week. [D2]

Professional experience and qualifications

It is recommended that
professionals involved in providing intervention services to young
children who have a communication disorder have expertise and
experience with infants, toddlers, and their families, and be
qualified and appropriately credentialed under the professional
practice acts of New York State. [D2]

The Cultural Context of the Child's Environment

A child's life is always embedded
in culture. It is always essential to consider and respect the
family's culture and primary language when providing interventions
for children with communication disorders. [D2]

Determining the language to be used in the intervention

Although it is important to
consider the parents' preference in determining the language used
in the intervention, it is strongly recommended that any
intervention be conducted in the primary language used in the home.
This is important so that:

natural interaction and communication can occur between child and parent at home

the child can develop a firm
foundation in a first language before any attempt is made to
introduce a second language to the child [D2]

It is important that parent
education and counseling, including written materials, be in the
primary language of the family.
[D2]

It is recommended that any direct
speech/language therapy be conducted by a professional who is
fluent in the language of the child and the family. [D2]

Because parent involvement is such
an integral part of the development of speech and language of
infants and young children, it is strongly recommended that
professionals involved in parent education and training be
competent in the language of the family and familiar with its
culture. [D2]

Using a translator and/or cultural informant

If a professional fluent in the
child's primary language is not available, it is recommended that a
specially trained translator interpret for the professional
providing the intervention during information sessions.
[D2]

If the professional providing the
intervention is not familiar with the culture of the family, it is
important to have a cultural informant to advise the professional
on issues that may cause misunderstanding during the course of
therapy. [D2]

It is recommended that a person
familiar with the culture and language of the family review
intervention techniques and materials to determine if they are
culturally appropriate.
[D2]

Training a translator and/or cultural informant

It is recommended that interpreters
assisting in the intervention process be trained by the
professional providing the intervention to provide culturally and
linguistically accurate interpretations of the child's behaviors
and to participate in the specific intervention program.
[D2}

It is recommended both that the components of interpreter/translator training include:

a review of the intervention materials

a discussion of the procedures

a demonstration of the techniques to be used [D2]

If the interpreter serves as a
cultural informant to advise the clinician on the cultural
appropriateness of intervention materials or techniques, it is
important that the interpreter be trained to administer stimuli
accurately, judge the child's response, and make or suggest
modifications in procedures when appropriate. [D2]

Major Approaches for Speech/Language Interventions

Speech and language interventions
for young children with communication disorders include a variety
of methods and approaches. Some interventions are focused directly
on the child (often called direct interventions). Other
interventions focus on teaching intervention skills to the parent
or another individual who then works with the child (often referred
to as indirect interventions).

Of the interventions that focus
directly on the child, some involve working with the child in individual therapy sessions in which the therapist works
one-on-one with the child, either alone or in a setting which
includes other typically developing children. This type of
intervention can occur in the home (a home-based program) or at
some other location (such as professional's office, school,
daycare, or community setting).

The choice of setting for individual
speech/language therapy will depend on a variety of factors
relating to the individual child's needs and family situation.
These factors might include age and developmental level, the type
and severity of the communication disorder, other developmental
deficits or medical problems, the family's interest in and ability
to participate in the intervention, the cultural context of the
child and family, and the language used by the child and
family.

Other interventions involve working
with children in a group setting in which there are
two or more children receiving similar interventions. Group
interventions range from groups as small as two children to large
classroom settings. In this guideline, group speech/language
interventions are defined as interventions that involve a
professional working with two or more children. The size,
participants, and structure of the group may vary depending on the
needs and abilities of the child, intervention techniques, and the
setting. Some group interventions may include parents as well as
children.

Group interventions may occur in a
clinical, classroom, or community setting (such as the
professional's office, day care, or preschool). More informal
settings might include opportunities for children to interact at
library or recreation programs. In somewhat older children, group
interventions may take place in a preschool setting. Group
interventions in preschool settings may be either specialized
classes for children with developmental disorders or they may
include peers with normal language development.

The studies reviewed as evidence to
develop recommendations in this section evaluated both group and
individual interventions for populations of children with different
types of communication disorders. Some were studies of children
with speech or language delay; some studies looked at children with
specific language impairment, and other studies evaluated children
who had a communication disorder associated with other
developmental problems.

Individual Speech/Language Therapy Approaches

Recommendations

The role of individual speech/language therapy in treating communication disorders

Individual speech/language therapy
(either as a sole intervention or in combination with group
interventions) may be useful in treating young children with
communication disorders.
[B]

Individual speech/language therapy
may be especially important at the beginning stages of treatment as
specific targets are established and as the child becomes
accustomed to the professional and use of particular
techniques. [D1]

It is important to consider that
individual speech/language therapy as the sole intervention method
may produce less generalization of language skills to other
situations than group interventions that involve multiple
conversational partners.
[B]

Working collaboratively with parents

It is important that professionals conducting individual speech/language interventions:

establish good communication and rapport with the parents and family

work collaboratively with the
parents in deciding on the targets of the interventions and in
monitoring progress

Group Speech/Language Therapy Approaches

Recommendations

Using group speech/language interventions

Depending on the age and language
development level of the child, speech/language intervention in a
developmentally appropriate group may be useful for young children
with communication disorders (either as a sole intervention or in
combination with individual therapy). [B]

It is important to recognize that
the specific intervention techniques are often similar for both
individual and group intervention settings. [D2]

Group speech/language interventions
are useful to facilitate generalization of language skills to other
settings. In contrast, interventions provided directly by a
professional in individual therapy sessions may be more useful in
establishing the structural aspects of language. [B]

For children participating in group
interventions, it may be useful to add individual sessions to
establish structural aspects of language. This may be particularly
useful for children from 24 to 36 months. [D1]

Including parents in group interventions

It is important to provide
opportunities for including parents in speech/language group
interventions for young children because these may
help:

provide parents with support,
information, and education to enhance communicative
development

facilitate generalization of the child's language skills to other settings [D1]

Formal Parent Training Programs

Parent training, as the term is used
in this guideline, refers to a formal program in which a
professional instructs parents in strategies and methods for
enhancing their child's speech and/or language development. Formal
parent training programs provide an opportunity for parents to take
a more primary role in implementing speech/language interventions
for their child.

Most of the formal parent training
programs evaluated by the panel and used as the basis for
recommendations included group training sessions to teach parents
general strategies and approaches as well as sessions in which
professionals met individually with the parents of each child. In
the individual sessions, professional demonstrated techniques for
individualizing the interventions to the child and provided
feedback on the parents' implementation of these techniques. One of
the programs involved only individual training sessions with
parents in the home.

Recommendations

It is important to recognize that
some parents can be successful primary intervention agents,
provided that:

a professional qualified to provide
speech/language interventions consults with the parent on a
periodic basis

adequate amounts of professional and parent time are allocated for parent training

there is ongoing monitoring of the child's progress by the professional providing consultation to the parent [A]

Formal parent training programs are
strongly recommended for parents who serve as primary intervention
agents for their child with a communication disorder. [A]

Formal parent training programs may
also be useful for parents whose children are involved in either
individual or group speech/language therapy (where the parent is
not the primary intervention agent). [D1]

Components of parent training

It is strongly recommended that parent training programs include:

instruction regarding general
techniques and approaches as well as ways to individualize
intervention methods to their own child's needs

direct instruction in the treatment approach and the specific targets of the intervention

demonstrations of the specific intervention techniques

feedback on implementation of intervention techniques with their child [A]

It is recommended that parents be
taught specific techniques to help facilitate their child's
communication development. These techniques may
include:

the promotion of communicative interaction

modeling of target communicative behaviors

the use of child-oriented strategies [A]

Discussing intervention targets with parents

In discussing intervention targets
with parents, it is important that the professional providing the
intervention emphasize the following considerations:

Focusing the intervention first on
increasing the amount, variety, and success of verbal and nonverbal
communication and then, if necessary, on
intelligibility

While encouraging intelligible
speech, it is important that progress not be slowed by focusing on
speech productions that are not expected at the child's particular
developmental level
[D1]

Assessing outcomes of parent training programs

As part of ongoing monitoring of
the child's progress, it is recommended that the professional
providing the intervention periodically assess outcomes of the
parent training program using both:

direct measures of the child's behavior

information provided by parents [D1]

It is recommended that assessment of outcomes from parent training programs include measures of:

changes in the parents' communication patterns when interacting with the child

the child's progress in meeting specific language targets as well as the child's overall progress in communication [D1]

It is important for the
professional providing the intervention to monitor the child's
progress closely and modify the intervention strategy if progress
is not being made as expected.
[A]